Chapman, John NEW YORK STATE DEPARTMENT OF HEALTh�1 t ((A
Vital Records Section Burial - Transit Permit
I Name First Middle Last Sex
{ John P. Chapman Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 25, 2011 69 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Fort Edward Street Address 44 State Route 197
CI Manner of Death Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
WW1 Medical Certifier Name Title
Thomas Kandora, M.D. Dr.
Address
Broadway Fort Edward, NY 12828
Death Certificate Filed Distj t Numb Register Number
City, Town or Village .'' '7D
❑ Burial Date Cemetery r Crematory
February 28, 2011 Pine View Crematory
❑ Entombment Address
X❑Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z fl Removal and/or Held
l 1 and/or Address
p Hold
0 Date Point of
a. Transportation Shipment
0' by Common Destination
tD Carrier
nDisinterment Date Cemetery Address
Date Cemetery Address
Li Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01098
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
}-. Remains are Shipped, If Other than Above
2 Address
III
O. Permission is he by ranted to dispose of the human re ain described a v as in Gated.
Date Issue Registrar f Vital Statistics A 44aQ
(sign ture)
District Number Place //'!
0
I certify that the remains of the decedent identifie above were disposed of in accordance with this permit on:
la Date of Disposition 02/28/2011 Place of Disposition Quaker Road Queensbury,NY 12804
W (address)
to
re (section) (lot number) (grave number)
CI;• Name of Sexton or Per on in Charge Premises (1 r`shor (please print)
z
Ill Signature Title a en)riale(--
(over)
DOH-1555 (02/2004)